CHAPTER 2
THE GLOBAL EPIDEMIC OF CHRONIC DISEASE: THE ROLE OF OUR FOOD SYSTEM
The chronic diseases that are sweeping across the globe and weighing down global economies can’t be cured by better medication or medical care. Food is the biggest cause of chronic disease and the economic burden it places on families, societies, and nations. While the cost of health care is only going to balloon as we move into the future, we don’t need to wait 35 years to see the damaging effects of our food system.
In 2019 The Lancet published an analysis of dietary risk factors in 195 countries based on the Global Burden of Disease Study, the most comprehensive study of the effects of diet on health ever conducted, covering a 27-year period.1 Despite the limitations of the study, the bottom line was this: A diet without enough healthy foods (fruits and vegetables, nuts and seeds, whole grains, etc.) and with too many bad foods (processed foods, refined grains, sugar-sweetened beverages, trans fats, etc.) accounted for 11 million deaths and 255 million years of disability and life years lost. Most striking was the finding that the lack of protective foods (whole real unprocessed foods) was as or more important in determining risk of death than the overconsumption of processed foods. This is a big deal.
We are facing an unprecedented threat from biological weapons of mass destruction—the food produced by our food system that drives disease, suffering, environmental destruction, and climate change.
Imagine if an infectious disease like Ebola or Zika or AIDS or cholera killed 11 million people a year. We would have a global effort to find a cure, to address the public health factors—and governments, scientists, philanthropists, and businesses would be aligned to fight these threats. Yet there is silence when it comes to our global response to the most common kinds of preventable deaths.
I was recently at the Milken Global Conference listening to a panel of the leading thinkers and actors in health care—the head of the National Institutes of Health, the CEO of the Bill and Melinda Gates Foundation, the head of the Center for Medicare and Medicaid Services, and the CEO of Kaiser health systems. They spoke of important things—eradicating polio, malaria, and AIDS, gene editing to cure rare genetic disorders, improving the interoperability of medical records, data sharing, and improving medical payments systems to pay for value. All great advances. But no one talked about the elephant in the room: the tsunami of disease, death, and costs driven by our poor diet, not to mention the effects of our food system on the environment, climate, and even social justice. It dwarfs every other problem.
The reason this problem is pretty much ignored or attacked piecemeal is that this epidemic has come on fast and furiously over the last 40 years and blindsided society and governments. And better medication or medical care can’t solve these chronic diseases. The solution? Our forks.
Yes, it is true. There is no denying it now. The food we eat (or the food we don’t eat) is the single biggest cause of death worldwide, exceeding tobacco and every other known risk factor. Historically, infections, poor sanitation, or what we call communicable disease caused most deaths. Now more than 70 percent of deaths worldwide are from what we call “noncommunicable disease,” conditions like heart disease, obesity, type 2 diabetes, cancer, and dementia. However, as we’ll see in Part 4, there is a problem with the term noncommunicable. It implies that these conditions—such as heart disease, cancer, diabetes, dementia, and depression, among others—just appear randomly, or that they are the result of poor judgment. However, these diseases are highly contagious and driven by the structural environment—government policies, poverty, and a pervasive and increasingly toxic global food system and environment that create conditions ripe for poor diet and chronic disease, often referred to as the social determinants of health.
We often blame the victim for these diseases. No one blames someone for getting malaria or tuberculosis. But for chronic disease we put the blame on individuals, on personal responsibility. It turns out that it is our social environment—what Paul Farmer from Partners in Health has called structural violence—the social, economic, and political conditions that drive disease. If we live in a world where our food system mainly produces disease-causing foods, where a food carnival makes it almost impossible to make the right choice, where our government supports the production and sale of these foods, where these foods are biologically addictive, then personal choice is a fiction.
The science is clear: Noncommunicable diseases, it turns out, are very communicable. You are more likely to be overweight if your friends are overweight than if your family is overweight.2 Depending on your neighborhood, your life expectancy may be 20 to 30 years shorter than that of folks from another county, city, or state. Simply moving an overweight diabetic from a low socioeconomic neighborhood to a slightly better one leads to weight loss and improvement in diabetes, without any other intervention.3
This is far more than an issue of personal choice and behavior. The food we have available to eat (ultraprocessed food) and the food we don’t eat (fruits and vegetables and whole foods) are determined by the food system itself—what we grow and produce and how we market and distribute it, and what we don’t.
According to the lead author of the Lancet study, “There is an urgent and compelling need for changes in the various sectors of the food production cycle, such as growing, processing, packaging, and marketing. Our research finds the need for a comprehensive food system intervention to promote the production, distribution, and consumption of healthy foods across nations.” Basically, our whole food production system from the field to the fork focuses on producing foods that make us sick and fat and cause us to die early, rather than on foods that make us healthy, prevent disease, and help us live a long, productive life. Sadly, both the intended and unintended consequences of our global food system provide too much of the bad stuff and not enough good stuff. It is killing us.
THE PERILS AND PROMISE OF FOOD
I recently saw a picture of a beach scene from the 1970s and another from Woodstock. I could not find a single image of anyone overweight, never mind obese, in a sea of humans. What has happened to us reminds me of the story of the frog in boiling water. If you put a frog in boiling water, it will jump right out. If you put a frog in tepid water and slowly heat it up, the frog will just boil to death. That is us today as we head into the middle of the twenty-first century.
Over the past 40 years, since the government’s first dietary guidelines encouraged us to cut the fat and increase the carbs (a deadly idea), and since the expansion of extractive, industrial agriculture, which has produced hundreds of thousands of food-like substances from a very few raw materials (wheat, soy, and corn), we are now a nation where being an optimal weight is an anomaly. We have created the worst diet in the world and are exporting it to every country on the planet.
When I graduated medical school, there was not a single state with an obesity rate over 20 percent. Now there is not a single state with an obesity rate under 20 percent, and within the last few years we have seen many states surpass an adult obesity rate of 40 percent and most others are closing in on 40 percent.4 Obesity, now officially considered a disease, and its downstream diseases (heart disease, cancer, type 2 diabetes, dementia, arthritis, and others) are literally weighing down our species, our communities, our environment, and our economy, depleting human, social, economic, and natural capital in ways both visible and invisible.
Approximately 60 percent of our calories in the United States come from ultraprocessed foods, with the poor, minorities, the young, and the less educated consuming the most.5 This leads not only to obesity and disease, but also to micronutrient deficiencies and malnutrition. More than 90 percent of Americans are deficient in one or more nutrients at the level that creates vitamin deficiencies such as scurvy, rickets, and others.6 The paradox is that we provide our population with too many calories and not enough nutrients. We are overfed and undernourished. Surprisingly, the most obese adults and children are the most malnourished.7 And globally this problem is even worse.
What is the root cause of this tsunami of chronic disease that affects more than one in two Americans and increasingly our global population? The reasons are complex, but it is a combination of physical inactivity, smoking, excess alcohol consumption, and diet. But our diet and our food system are by far the biggest contributors to the structural factors that have led to this epidemic of chronic disease. The shift in our food quality, our food and health policies, our agricultural practices, and business “innovations” in product development and marketing in the more than $15 trillion food industry (food8 and agriculture9) have created a disease-creating food system and economy. This shift grew from both the unintended consequences of policies and practices thought to be innovative and “better for you” such as the promotion of margarine and shortening—which has likely killed millions since the development of Crisco in 1911—and the deliberate practices and policies driven by an amoral food system hungry for profit and market (or stomach) share.
But we can change this trajectory—first in our own homes, then in our country, and finally globally.
THE PROBLEM OF ULTRAPROCESSED FOODS
Despite the fact that we produce more than enough food for our global population, we still have more than 800 million people who go to bed hungry and 2 billion who have nutrient deficiencies that result in stunting, impaired cognitive development, risk for infectious disease, and chronic diseases, among other risks. At the same time, 2.1 billion go to bed every night overweight. As we will see in Part 5, the world food system produces an average of 2,870 calories per day for the 7.5 billion humans on the planet. The average calorie need per person is 2,550. Globally, we produce 320 calories more than we need per person per day. We currently produce enough food for 10.5 billion people.10 But even in the United States food insecurity affects 12 percent of the population, or about 15 million people, including 6.5 million children.11 And the 46 million Americans on food assistance, or SNAP, half of whom are children, are at risk for hunger and food insecurity.12 I am embarrassed to live in the richest country in the world, where one in four children are food insecure.
How is it possible that we create so much food but so many people are still undernourished? Food security is defined as access to affordable nutritious food, but when SNAP was developed, “nutritious” meant vitamin-fortified starchy calories. The calories are abundant, but the nutrition is not, technically leaving nearly everyone on the planet food insecure because of lack of access to whole fresh nutrient-dense foods.
It may be surprising that the most food insecure are also the most obese, have twice the risk for type 2 diabetes, and are also malnourished because much of the food we produce is calorie-rich, nutrient-poor processed food and sugary beverages.13 Calorie for calorie, these foods cost less than nutritionally rich fruits and vegetables or whole foods. If you have $1, you can purchase either 1,200 kcal of cookies or potato chips or 250 kcal of carrots.14 And if you are poor and live in a food desert, good luck finding a carrot. The cost of processed food per calorie is low. The cost per nutrient is high, very high, often because there are almost none! Ultraprocessed foods and the food system that produces them are at the root of the chronic diseases that account for 80 percent of the deaths from noncommunicable disease worldwide (heart disease, diabetes, cancer, etc.).15
A recent study of more than 44,000 people published in JAMA Internal Medicine found that for every 10 percent increase in the intake of ultraprocessed food, the risk of death increases by 14 percent.16 If 60 percent of our calories come from processed foods, the math adds up to a lot of unnecessary, food-caused, preventable deaths.
Just as the wrong foods can cause disease and death, the right foods can dramatically reduce disease and death. Mounting research proves that food is medicine and demonstrates how whole foods, especially an increase in vegetables and fruit, can prevent or reverse chronic disease.17 At Geisinger Health Systems, providing food-insecure poorly controlled type 2 diabetics with a year’s worth of whole foods reduced health care costs by 80 percent and dramatically improved their health outcomes.18
According to Dr. Dariush Mozaffarian, “The idea of food as medicine is not only an idea whose time has come. It’s an idea that’s absolutely essential to our health care system.”
The truth is that our agricultural system doesn’t produce enough for everyone to eat even the minimum requirement of fruits and vegetables, which may be even more important to prevent disease than reducing industrial processed foods (although that is still critically important). We have all heard we should eat five to nine servings of fruits and vegetables a day (one serving is a half cup).19 This is a bare minimum, with some research suggesting we should be consuming 15 servings (about 8 cups) a day for optimal health. The government’s dietary guidelines advise us to make 50 percent of our plate fruits and vegetables. Globally about 78 percent of the world’s population does not eat the minimum of five servings of fruits and vegetables a day.20 We tell people to eat more fruits and vegetables, but we don’t grow them. How does this make any sense?
Even worse, ultraprocessed foods (corn, soy, wheat) are turned into sugars, refined oils, and starch that are the building blocks of processed food, which is made into every size, color, and shape of extruded food-like substance but is essentially the same garbage. These foods hurt us twice. First, they damage the environment by depleting soil, water, and oil resources and are the largest source of greenhouse gases. Second, they are the greatest cause of human suffering, disability, disease, and death.21 We produce far too many calories for the world’s population and not enough of the real nutrients, found in whole foods, needed to create health.
Refocusing our agricultural system along with our national and global food policies on production of foods that support human health and the restoration of natural capital (soil health, water quality and availability, drawdown of carbon, limits on fossil fuel, etc.) would go a long way toward reducing the economic, social, and human burden of chronic disease and improving the health of our soil, water, and climate.
A DECLINE IN LIFE EXPECTANCY
The data is clear. Those who consume the most of those ultraprocessed foods, the staple building blocks of industrial food, which are processed into white flour, high-fructose corn syrup, and refined soybean oil, are the sickest. They have higher body weight, more dangerous belly fat, and worse cholesterol and blood sugar.22 And they die sooner.
For the first time in human history, our life expectancy in the United States is on the decline for three years in a row. Over 4 million years of human evolution, life expectancy increased. At the turn of the twentieth century, it went from twenty-one to thirty-one years old. The number doesn’t reflect that nearly half the population died in childhood, making the average low. But from 1900 to 2000, life expectancy increased about 41 years, from thirty-one to seventy-two years old. In America we have more than doubled life expectancy through public health measures including sanitation, a dependable food supply, and vaccinations. Some minor gains were made by advances in medical care other than vaccinations, but that is a relatively small amount. But our current food system is eroding these advances.
Children born today are expected to live shorter, sicker lives than their parents. The average child born today will live five fewer years than their parents, and if they are poor or socially disadvantaged, they will live 10 to 20 fewer years than their parents. One in three children born today will have type 2 diabetes in their lifetime. These trends have been increasing year over year. Now for three years in a row, we have seen life expectancy go down. Some of this decline may be due to the opioid epidemic, drug overdoses, suicide, and mental health disorders. Opioid deaths have risen to 70,000 a year. While important to address, that number pales in comparison to the almost 700,000 deaths a year from lifestyle (aka diet)-related cardiovascular disease alone. There has been talk of declaring a national emergency to stem the deaths from opioid overdose. Perhaps we should have a similar initiative to address deaths from poor diet.
The maps of life expectancy tell a clear story. When overlaid upon the maps of obesity and type 2 diabetes, most prevalent in the South, there is almost a complete correlation between the states with the highest obesity and diabetes rates and those with the lowest life expectancy. Death rates from heart disease, diabetes, chronic liver disease (caused by sugar and starch), stroke, and Alzheimer’s are on the rise.23 The disparities in life expectancy in this country are driven by disparities in education, income, and socioeconomic status affecting the poor and minorities that result in obesity and metabolic disease caused by poor diet.24
There has also been a rise in allergic, autoimmune, and inflammatory conditions linked to poor diet.25 Mental health has also declined, with increasing rates of depression, suicide, behavior problems, ADHD, and neurodevelopmental disorders in children, much of which has been linked to poor diet,26 while good mental health has been linked to a healthy diet.27
FOOD FIX: EAT FOR THE HEALTH OF HUMANS AND THE PLANET
What is the best diet for humans, our society, and the planet? What we eat is important not only to us, but also to almost everything that matters. It would seem we should have a simple answer to this question, but there is vast disagreement from a variety of experts. I have spent the last 40 years studying nutrition, grappling with the changes in recommendations and diets, and treating more than 10,000 patients with food as medicine.
Sadly, the public is at the mercy of these constantly changing debates. Eggs were bad, then they were good, and now they are bad again. Fat was bad, now it’s good, but controversy exists about whether to cut saturated fat or increase refined plant-based oils. Some science shows that meat is bad and increases the risk of heart disease, cancer, and death; other science reports that meat is benign, even healthy and necessary for optimal nutrition. (Chapter 17 will help clear up some of the confusion.)
On the one side is the regenerative agriculture movement, which suggests that animals are part of the natural biological cycle necessary to create sustainable ecosystems, that animals must be integrated into farms to regenerate soil, enabling it to store massive amounts of carbon and water. These practices can reduce the need for factory-farmed meat and its overuse of antibiotics, pesticides, herbicides, and farming practices that deplete the soil and can be done at scale more profitably than feedlots. With 40 percent of agricultural lands suited only for grazing, this seems like a good idea. Even if you wanted to grow vegetables or grains on them, you can’t. According to Nicolette Hahn Niman, a vegetarian regenerative rancher, the problem is not the cow, but the how. Feedlot beef, hogs, and chickens—or regenerative farms that include animals as an essential part of ecosystem restoration? (We’ll dive into this in Part 5.)
Others suggest that eating meat will destroy our health and that cattle are the equivalent of the atomic bomb in terms of the destructive capacity for the climate and inhumane treatment of animals. That a meatless diet is the only way to save our health and the planet. That animal products should not be part of a healthy diet. That vegan and vegetarian diets prevent disease and prolong life. Compared to our standard processed diet, plant-based diets are better. This does not automatically mean that diets of whole foods including sustainable, regeneratively raised animal foods are bad. Data on both vegetarian and meat-based diets are primarily studies of large populations. Some studies show no difference between omnivorous diets and vegetarian or vegan diets. Some show that vegetarian diets are healthier. Some show that diets with animal protein and fat are healthier than diets high in cereal grains. No wonder people (including doctors and even many scientists) are confused. (Chapter 9 will help clear up some of this confusion.) However, the totality of the scientific evidence makes it very clear that a whole foods, unprocessed diet is better for you and the planet. With one caveat: Factory farming of animals is bad for you, for them, and for the planet. Regeneratively raised animals can not only prevent the environmental and climate harm of factory-farmed animals but actually restore ecosystems and reverse climate change.
These simple arguments often ignore the complexity and nuances beyond the sound bites.
The types of studies we need haven’t been done. We have to rely on basic science, smaller clinical trials, and the totality of all the data. A large, long-term randomized controlled study of a whole-foods-based regenerative diet that includes animals or one that is vegan has not been done and is very difficult to do. It would take decades, billions of dollars, and hundreds of thousands of study participants who strictly follow a specified eating protocol. Can you see why this hasn’t and can’t be done? Just to study a few hundred people over a few months while strictly controlling their diets can cost tens of millions of dollars and still may not be able to predict long-term outcomes.
Yes, factory-farmed meat is bad for us and the planet. No one is for it (except Big Ag). Regenerative grass-fed meat can restore ecosystems, improving soils while sucking carbon from the atmosphere and increasing water storage in soils. It also increases biodiversity of the soil, which is critical for human survival, and can be employed on lands unsuitable for other agriculture.
The simple “plants are good, meat is bad” argument is nuanced. What plants? What meat? Industrial soy, no. Vegetables from a regenerative farm, yes. Factory-farmed steak, no. Regeneratively raised steak, yes. A recent independent life-cycle analysis by the sustainability experts at Quantis of regeneratively raised beef versus GMO soy burger (Impossible Burger) showed that you would have to eat one regeneratively raised beef burger to offset the net carbon emissions of one Impossible Burger.28 The soy burger is far better than feedlot beef, but it adds 3.5 kilograms of CO2 to the environment, while the regeneratively raised beef burger removes 3.5 kilograms of CO2. Soy is the main staple of “healthy vegan” meat replacements and plant-based burgers. So, your soy burger or pea protein shake may not be so good for you or the planet after all. Since the soy from the Impossible Burger is made with GMO soy most likely sprayed with Roundup or glyphosate, it may have as much as 10 parts per billion (ppb) more glyphosate than those made from pea protein.29 Research shows that just 0.1 ppb of glyphosate is enough to harm your gut bacteria or microbiome.30 Just one Impossible Burger may have 110 times that much!
So what’s an eater to do?
Well, let’s get into the simple principles, based on the best available data we have today, combined with a spoonful of common sense, that will help prevent and reverse chronic disease, restore ecosystems, reverse climate change, and dramatically reduce the true cost of food.
What Is the Best Diet for Us and the Planet?
I have reviewed the research on nutrition and what makes up a diet that is good for you, good for the planet, and good for society. I have laid this all out in my book Food: What the Heck Should I Eat? And I provided a way to do it in my cookbook Food: What the Heck Should I Cook? To get a nuanced view of the research, an honest and nondogmatic, nonphilosophical view based on 40 years of studying nutrition and 30 years of applying it to thousands of patients, you can read the book. But here is my best attempt to summarize it.
What to Eat: Pegan Diet Rules
The diet wars are bigger than ever in history. Vegan, Paleo, keto, low-fat, high-fat, low-carb, high-carb, raw. The EAT-Lancet Commission recently published an analysis of diets that suggested that for healthy adults there is a “universal healthy diet.” The recommendations include a dramatic reduction in animal products and an increase in plant-based foods. It presents a flexitarian approach adapted to each local culture and environment. It’s a step forward for sure, but it is important to understand that the eat-less-meat argument is valid only in the context of current factory-farmed-meat production systems, not regenerative grass-fed and grass-finished meat. In fact, as we will see in Part 5, eating more of the right meat may be one of the key ways to reverse climate change.
Each of us must find the right diet for our genes, metabolism, age, dietary preferences, beliefs, and so on. Moral, ethical, and religious considerations are important on a personal level. I would never tell my Buddhist monk patients to eat meat. But I would guide them in the best possible way to optimize a vegan diet, showing them how to maximize protein requirements and indicating which nutritional supplements must be taken to ensure nutritional adequacy.
The best person to listen to is your own body. How does it feel? Try different approaches. More fat, less fat. More carbs, less carbs. More protein, less protein. But one principle remains: It should be whole food, real food, recognizable from field to fork. Pay attention to your energy, weight, digestion, and health conditions. Your body will tell you what it likes. But the core guidelines for a healthy diet apply to everyone: Your diet should be aspirational, not perfect. It should contribute to better health for you, a better world for humans, including food workers and farmworkers, and a better world for the environment, our climate, and our economy.
There are a few simple principles that I have jokingly called the Pegan Diet (poking fun at the extremes of the Paleo and vegan diet camps). These Pegan rules (which are not so much rules as guidelines) attempt to create flexibility within those parameters. You can’t go wrong following these principles. And any unbiased scientist who has read the scientific literature on nutrition would have a hard time arguing with these guidelines.
Eat mostly whole plants. No argument from anyone here. Think plant rich, not necessarily plant based. And remember french fries, Coke, Twinkies, and Lucky Charms are all plant-based foods! More than half your plate should be covered with veggies. The deeper the color, the better. The World Health Organization (WHO) recommends five servings a day. That is the minimum. It should be fifteen servings, or 7 to 8 cups of veggies and fruit a day.
Go easy on fruits. If you are fit and healthy, more fruit is fine. But if you are overweight (like 70 percent of Americans), then go easy on the fruit. I find that most of my patients feel better when they stick to low-glycemic fruits like berries and enjoy other, sweeter ones as a treat.
Eat more foods with healthy fats. Start with fats in whole foods. Good fats include nuts, seeds, avocados, pasture-raised eggs, extra virgin olive oil (don’t heat), avocado oil (good for cooking even at high heat), and organic virgin coconut oil, omega 3 fats from fish, and even animal and saturated fat, and 100 percent grass-fed and grass-finished or sustainably raised meat, grass-fed butter, or ghee.
Eat more nuts and seeds. They have universally been shown to prevent and reverse disease.
Choose regeneratively raised animal products whenever possible. They are better for you and better for the animals and help draw down carbon and reverse climate change. The data on meat is conflicting, mostly because of the challenges of nutritional science. We’ll review it in Part 5. Vegetables should take center stage, and meat should be the side dish. Servings should be 4 to 6 ounces per meal (ideally also regeneratively raised or no-till organic, which is hard to find but addressed in Part 5). The “eat less meat to save the planet” meme is not so simple. In fact, more of the right meat regeneratively raised may actually be a big part of the solution to climate change (and conserving water, increasing biodiversity, and reducing agricultural pollution), according to the 2019 IPCC report on climate and agriculture mentioned earlier.
Eat pasture-raised eggs. They are rich in vitamins, minerals, antioxidants, protein, and more. They are also a cheap source of high-quality and bioavailable nutrients including B12, which you can’t get from a vegan diet. The 2015 Dietary Guidelines determined that dietary cholesterol does not cause heart disease and eliminated recommendations to cut it out of our diet. Dietary cholesterol, the type found in foods like eggs, doesn’t significantly impact your blood cholesterol levels. In fact, your blood cholesterol is actually worsened more by sugar than by fat, and some fats, like olive oil, avocados, and nuts, actually improve your cholesterol.
Eat sustainably raised or harvested low-mercury fish and high-omega-3 fish. Choose low-mercury and low-toxin varieties such as sardines, herring, anchovies, mackerel, and wild-caught salmon (all of which have high omega-3 and low mercury levels). Avoid big mercury-laden fish such as tuna, swordfish, Chilean sea bass, and halibut. See www.ewg.org for a guide on safe fish consumption.
Eat only unprocessed or minimally processed whole grains (not whole-grain flours). All grains can increase your blood sugar. Stick with small portions (½ to 1 cup per meal) of low-glycemic grains like black rice, quinoa, teff, buckwheat, or amaranth. They can be a source of protein, but it takes 3 cups of quinoa to provide the same amount of protein found in 4 ounces of chicken. Beware of modern wheat—it is mostly consumed as refined flour (aka sugar), which is worse for your blood sugar than table sugar. The hybridized version has higher starch content and more inflammatory types of gluten and is sprayed with the toxic herbicide glyphosate right before harvest, then preserved with calcium propionate, which has been linked to behavioral issues, headaches, and stomach inflammation. In fact, in the most rigorous type of study in children, a randomized, placebo-controlled crossover trial, calcium propionate in bread caused kids to be irritable and restless and have trouble focusing and sleeping. And it’s in every processed food that contains wheat and all bread. You can eat organic wheat berries, but stay away from the rest.
Eat beans. Beans can be a great source of fiber, protein, and minerals. But they cause digestive problems for some, and the lectins and phytates they contain can impair mineral absorption. Pressure cooking is the best way to get the most out of your beans with the least risk. Moderate amounts (up to 1 cup a day) are okay. But remember it takes 3 cups of beans to get the same amount of protein found in 4 to 6 ounces of meat, fish, or chicken. Just a side note on beans versus meat for protein. The oft-quoted figure that 1,800 gallons of water is required to produce 1 pound of beef while only 216 gallons is required to grow 1 pound of soybeans is based on factory-farmed meat, where large amounts of water are used to grow the corn used to feed the cattle. However, 97 percent of water used to raise grass-fed and grass-finished beef is green water (rainwater), while the growing of beans requires irrigation, or blue water from lakes, rivers, and aquifers, which uses 5.25 times more water per acre than growing grasses for grass-finished beef.31
Stay away from sugar and anything that causes a spike in insulin production and blood sugar—flour, refined starches, and carbohydrates (which sadly make up more than half of most diets). Think of sugar in all its various forms as an occasional treat. “Don’t drink your sugar calories” may be the most important diet advice you will ever get.
Stay away from most refined vegetable, bean, and seed oils, such as canola, sunflower, corn, grapeseed, and especially soybean oil, which now accounts for 10 percent or more of the calories in processed foods. They are unstable, easily oxidized, processed with heat and toxic solvents, and can be inflammatory. Stick with the fats noted previously.
Choose the right dairy. Dairy today is not what it used to be. It is bad for the environment (from cows raised in feedlots) and not well tolerated by most people (except Northern Europeans and the Masai people) because 75 percent of the world’s population is lactose intolerant. The way we raise dairy cattle is bad for the cows, the environment, and humans. Dairy has been linked to cancer, osteoporosis, autoimmune disease, allergic disorders, digestive problems, and more. Although in my clinical practice I find that most patients do better without dairy, some studies have shown reduced risk of type 2 diabetes, heart disease, and stroke among other benefits. Find dairy from heirloom cows that contain A2 casein, which doesn’t cause the same digestive or inflammatory problems as modern cow products. Try goat or sheep products instead of cow dairy; they also contain A2 casein. Some producers such as Organic Pastures raise grass-finished A2 cow milk. And always go organic and 100 percent grass-fed.
Stay away from pesticides, herbicides, antibiotics, food additives, hormones, and, ideally, GMO foods. Choose foods raised or grown in regenerative ways if possible. Also, no hormones, pesticides, herbicides, antibiotics, chemicals, additives, preservatives, dyes, artificial sweeteners, or other junk ingredients.
Eat for you and the planet. Remarkably, food that is good for you is also good for the environment, our depleted soil, our scarce water resources, and the biodiversity of plants, animals, and pollinators, and it helps reverse climate change. When choosing any food in any category explore where and how it was grown. Was it grown regeneratively, organically, and sustainably with no or minimal use of agricultural chemicals? While it may seem healthy to eat a “plant-based” burger, ask how the raw materials were grown. Were the soybeans doused in glyphosate and pesticides and farmed in ways destructive to the soil and in ways that overuse our scarce freshwater resources? Does it contain highly processed ingredients or novel proteins with unknown long-term effects? Choosing the right foods also helps invigorate the economy, heals chronic disease and helps end social injustice, restores the environment, and reverses climate change. It’s a win-win-win-win on all sides. This way of eating allows for vast flexibility within many cultures and dietary preferences. While there may be nuances in interpretation of the data, these principles can form the foundation of a universally healthy diet. And they include sustainability principles that will restore soils, preserve water and biodiversity, draw down carbon, reverse climate change, reduce the use of pesticides, fertilizers, and herbicides, and save trillions in health care costs, among other benefits.
FOOD FIX: FOOD AS MEDICINE
Not too long ago a group of doctors and public health experts at Massachusetts General Hospital noticed something striking: Many of the patients who routinely showed up in the emergency room requiring the most medical services were also the patients who seemed to be the most nutritionally vulnerable. They were patients with heart disease, type 2 diabetes, cancer, and other largely food-related chronic diseases. For hospitals and health insurers, these are among the highest-cost, highest-need patients. Working with a local nonprofit group called Community Services, the doctors decided to launch a study to see whether providing these patients with nutritious meals would have an impact on their health care outcomes.
The researchers recruited Medicaid and Medicare patients and split them into groups that either received nutritious meals or did not receive nutritious meals. What the study found was astonishing. The patients who had nutritious meals had fewer hospital visits, ultimately resulting in a 16 percent reduction in their health care costs. And that was after deducting meal expenses. The average monthly medical costs for a patient in the nutrition group shrank to about $843—much lower than the roughly $1,413 in medical costs for each patient in the control group.32
Another group of public health experts in Philadelphia studied what happened when a nonprofit health group called the Metropolitan Area Neighborhood Nutrition Alliance (MANNA) delivered healthy meals to people with diabetes, heart disease, cancer, and other chronic diseases. Over twelve months, the patients in the nutritious meal group visited hospitals half as often as a control group and stayed for 37 percent less time. Ultimately, their health care costs plummeted more than 50 percent, or $12,000 a month per patient.33 Considering that the sickest 5 percent of patients account for 50 percent of overall health care costs in the United States according to the Agency for Healthcare Quality and Research, providing meals to the sickest provides a big return on investment.34 The problem is that insurance will pay for expensive hospital stays but not for food that could literally save billions in health care costs. This must change.
A similar effort is underway in California, where researchers are studying the health care impact of providing nutritious meals to 1,000 chronically sick patients insured by California’s Medicaid program, known as Medi-Cal.35 Studies have shown a 32 percent reduction in health care costs and a 63 percent reduction in hospitalizations.36 Many of these programs are funded through private donations and coordinated by the national Food Is Medicine Coalition, which is a group of nonprofits that want to use nutrition to solve the health care and chronic disease crisis. The Food Is Medicine group hopes to get these medically tailored meals included in health care coverage.
These groups recognize what our federal government sadly does not: To tackle the crisis, our national food policies must be aligned with our health care policies. Instead of just treating rampant chronic diseases with medication and surgery, we have to start preventing and treating with food.
A CASE STUDY ON FOOD AS MEDICINE
At the Cleveland Clinic Center for Functional Medicine, we see daily how food can transform chronic disease and obesity. Janice, a patient there, provides a clear example of the power of eating well. She joined one of our group programs and with the support of her peers and our staff, she did the impossible. Only it’s not impossible because it happens every day when food is used as medicine.
Janice lived in the environment that surrounds us all—a toxic nutritional landscape, or food swamp, compounded by confusing science, media headlines, food industry marketing, and government regulations and policies that make the right choice the hard choice and the easy choice the wrong choice.
Janice was dancing with death. At sixty-six years old she was severely obese, suffering from heart failure, type 2 diabetes, and coronary artery disease. She also had early kidney failure from diabetes, a fatty liver, kidney stones, low thyroid function, and emphysema, and was taking a boatload of medications, including insulin injections, blood thinners, cholesterol medications, blood pressure medication, diuretics, and more to “manage” her illnesses. She saw multiple specialists to care for her complex medical problems. She was on a low-calorie, low-sodium, diabetic diet, and her blood sugars and weight were still going in the wrong direction.
Janice had already had two stents put in her heart for blocked arteries and was headed toward dialysis and a heart transplant. At her heaviest she weighed 254 pounds, with a BMI (body mass index) of 43.6 (normal is less than 25 and obese is greater than 30).
She decided to join our Functioning for Life program, a ten-week group medical visit program supported by doctors, nutritionists, health coaches, and behavioral therapists. The fundamental premise of functional medicine is to address the root causes of disease. In her case, for almost all her issues, the problem was eating too much of the wrong foods and not enough of the good foods. She grew up in a household where all they ate was processed food. It was all she knew.
At her first visit her blood sugar was out of control, averaging almost 300 (optimal is less than 85, and 126 is the threshold for diabetes). Her hemoglobin A1c, a measure of the average last six weeks of blood sugar, was 11 (normal is less than 5.5). Her kidneys were failing; her blood pressure was high despite her medication. Her cholesterol was severely abnormal, at more than 350 (normal is less than 180), and her triglycerides were 306 (normal is less than 70). She had severe omega-3 fat deficiency, which can contribute to diabetes, high blood pressure, and heart disease. Her ratio of omega-6 oils from refined processed food to omega-3 fats was 15 (optimal is less than 4). And she was severely vitamin D deficient.
In the first three days of changing her diet to an anti-inflammatory, low-sugar, and low-starch diet higher in good fats and whole foods, she got off her insulin and her blood sugar improved. She was still very overweight, but her blood sugar went to normal in three days! It’s not the weight; it’s the food. In three months, she lost 43 pounds, got off all her medication, normalized her blood sugar, blood pressure, and cholesterol, and reversed congestive heart failure (which never happens in traditional medicine); her fatty liver went away, and her kidney functions normalized. In one year, she lost 116 pounds and went from 254 pounds to 138 pounds (see photos below). She went from unable to function most days due to fatigue, joint pain, and brain fog to feeling healthy.
Her blood sugar, kidneys, and cholesterol are all normal, and now she is not on any medication. Her diabetes is gone. Her blood sugar is in the 80s and her hemoglobin A1c is 5.5—totally normal. Her BMI went from 43 to 23! It was like a gastric bypass without the pain of surgery, vomiting, and malnutrition, and with the pleasure of eating delicious whole foods. She is thriving as an active member of her community, a great-grandmother, a grandmother, and a mother! She was retired and disabled and now is going back to work, traveling around the world teaching, and doing archaeological exploration. She saved $15,000 to $20,000 a year in medication copay costs, especially from the insulin (imagine what Medicare was paying). And that is just one person. Imaging scaling that to the 30 million diabetics in the United States. That’s a savings of $450 billion a year (most are not on as much medication as she was, but close). She said to me, “I felt I was done, and now I feel like I am beginning again!”
You may think this is impossible, but it is something we see every day at the UltraWellness Center, my practice in Lenox, Massachusetts, and the Center for Functional Medicine at the Cleveland Clinic, which I head. It is not a miracle. It is just good science. And this is possible when people switch from the ultraprocessed industrial diet that is killing them to real, whole foods.
FOOD FIX: SPREAD THE WORD
Follow Janice’s lead: Change your eating habits for your health’s sake and then take this way of eating into your world. Instead of being influenced by your family, your neighborhood, or your workplace, be the influencer.
1. Start a faith-based wellness program in your place of worship. In 2011, Pastor Rick Warren, Dr. Daniel Amen, Dr. Mehmet Oz, and I launched the Daniel Plan, a faith-based wellness program in Warren’s church. In the first week 15,000 people signed up; they lost a quarter of a million pounds in the first year by supporting one another in small groups to live healthier lives. Now the program is in more than one hundred countries and thousands of churches around the world. You can learn more at www.danielplan.com.
2. Be an agent of change in your workplace. Start a lunch group, rotating who brings healthy lunches for your group. Start a wellness group for walking or being active together. Get rid of the candy, doughnuts, and sodas. They are bad for both the employer and the employees, increasing sickness, disability, and costs.
What you choose to eat every day is the single most important thing you can do to create health, spread social justice, repair the environment, and reverse climate change. It is not all-or-nothing. Do your best. One bite at a time.
FOOD FIX: HEALTH CARE INNOVATIONS
Instead of being the country with one of the worst chronic disease epidemics, we could become a model for health. While there are many ideas proposed by many groups, here are a few that could make a big impact in addressing the burden of chronic disease. Many of these have been outlined in a key paper published in BMJ in 2019 entitled “Role of Government Policy in Nutrition—Barriers to and Opportunities for Healthier Eating.”37
Reimburse food as medicine. Change medical reimbursement to pay for food as medicine through all federal and state health insurance programs such as Medicare and Medicaid for at-risk populations. The data is clear. Giving people food instead of drugs saves money. A new study providing medically tailored meals to sick patients reduced hospital and nursing home admissions and saved about $9,000 per person per year after providing free food.38
Pilot projects include the $25 million Produce Prescription Program in the 2018 Farm Bill to test how doctors’ prescriptions of fruit and vegetables bundled with financial incentives, education, and better access can improve health outcomes and reduce the use of health care services. California provided $6 million in support of food prescriptions and medically tailored meals for chronic disease. Similar programs have found that health care costs are reduced by 55 percent and hospital and long-term-care admissions are reduced.39
In 2018, John Hancock turned life insurance upside down by making all their policies part of the John Hancock Vitality Program, which provides financial incentives for healthier lifestyles, including $600 a year for purchasing healthy food.40 These types of business innovations will inspire other businesses, proving that it’s possible to increase profits while promoting social good.
Geisinger’s Food Farmacy provided $2,400 in food to food-insecure diabetics with education and social support and reduced costs by 80 percent while improving health care outcomes.41 The Food Is Medicine Coalition, an association of twenty-seven member organizations in eighteen states and Washington, DC, that provides medically tailored food to people with serious or long-term illnesses, helps advance this strategy. There is even a bipartisan Food Is Medicine Working Group in Congress today.42 It’s a start. And the return on investment is dramatic.
Create a Food Savings Account, like a Health Savings Account (HSA), where money can be stored tax free in an account that can only be used to by whole, real, health-promoting foods. It could ultimately save billions in health care costs.
Fund research and change reimbursement to pay for functional medicine, a systems approach to addressing the root cause of chronic disease. Functional medicine is how we healed Janice. Imagine scaling an approach that changes both the medicine we do and the way we do medicine:
Addressing root causes
Using food as medicine
Treating the body as a system rather than a set of symptoms
Shifting delivery of care in the community, putting patients and communities at the center of health care, not doctors and hospitals
Using proven behavioral change strategies such as peer support models, group visits, and health coaching to change people’s lifestyle.
Vida Health is a company that provides digital one-to-one or group personalized health coaching via video, text, and an app. Their research has shown dramatic improvement in health outcomes, but it is not reimbursed. Eighty percent of health is determined by our lifestyle, our social environment, and our genes. Yet we spend more than 80 percent of our health care dollars on doctors and hospitals and medical care. Not the right target if we want a healthy nation.
Cleveland Clinic has been the first major academic medical center to start a clinical and research program in functional medicine to bring new thinking to how we address the burden of chronic disease, including cardiometabolic diseases like heart disease and type 2 diabetes, autoimmune disease, and mental health issues, among others. Innovations in care delivery must also be funded: community-based programs, group models of care, and digital solutions. Initial research at Cleveland Clinic has shown that this approach increases value—that is, better outcomes are achieved at lower cost.43 How many Janices will it take to make this available to everyone?
Virta Health developed an online program to reverse diabetes with a ketogenic diet, and within one year diabetes was reversed in 60 percent of the participants, 100 percent stopped their main diabetes medication, insulin was reduced or stopped in 90 percent, and there was an average weight loss of 12 percent, or 30 pounds, results rarely seen in medical research, where 5 percent is considered success.44 Yet this digital program, outside the health care system, is not reimbursed.
Integrate nutrition into health care through support for nutrition education in medical schools and by changing licensing exams to include nutrition, which would change what doctors have to study, thus forcing medical school curriculums to change. Reimburse nutrition visits for chronic disease and obesity. Integrate nutrition into electronic health records. Develop reimbursement and quality metrics, which will incentivize the integration of nutrition into medical practice. In other words, if doctors don’t document nutrition status and use food as medicine, they don’t get paid! Develop quality metrics and payment reform that support community-based programs to address the upstream causes of poor health. Integrate public health and health care.
FOOD FIX: BUSINESS INNOVATIONS
Innovations in food, health, medicine, and agriculture are among the hottest investment opportunities that exist today. Billions in capital are flooding into the system, often disrupting the traditional industries of food, agriculture, medicine, and health care.45 A 2015 report mapped out a $2.3 trillion annual investment opportunity in sustainable food and agriculture. Dr. Dariush Mozaffarian suggests a number of initiatives that could facilitate the already booming investment in food, ag, and health care solutions that can solve the major problems facing our current food system. Many examples of business innovations and solutions are highlighted throughout Food Fix.
Innovation incentives: Institute tax policy and other economic incentives across sectors (agricultural, retail, manufacturing, restaurant, health care, wellness) for development, marketing, and sales of healthier, more accessible, and more sustainable foods.
Opportunity zones: Expand and support opportunity zone incentives focused on food, nutrition, and wellness investments to improve equity and reduce disparities. Opportunity zones are tax incentives to encourage those with capital gains to invest in low-income and undercapitalized communities.
B-corporations: Encourage and highlight B-corporation status across these sectors to recognize and reward companies for integrating major social and environmental priorities for health, food justice, and sustainability.
Mission-driven investment vehicles: Encourage and convene investment vehicles that focus on food- and nutrition-related companies centered on health, equity, and sustainability.
National entrepreneurship: Develop and support a national strategy to build an ecosystem of evidence-based, mission-oriented innovation for a healthier, more equitable, and more sustainable food system.